Jordan: This is an assumption that feels awful to make. It’s also one that anybody who spends time on the front lines of healthcare, saw coming.
News Clips: With Coronavirus, the things that get people into ICUs, that require intubation and often lead to death. They are just those very comorbidities that are unfortunately disproportionately prevalent in the African American population.
The lack of access to healthy food sources is another factor that accounts for the stark difference in numbers of COVID-19 related deaths in predominantly African American and white communities.
The most vulnerable and poorest amongst the U S citizens are the worst hit.
Jordan: That data comes from the United States and the United States of course, has private health care.
So maybe you think, well, of course there’s inequality in health care down there, that’s their system. And this is where I’d like to produce all the race based Coronavirus data that we’ve collected in Canada and show you how we compare. Except I don’t have any. We don’t have any. In fact, we’ve barely even tried to figure out who is being disproportionately impacted by the virus up here.
It wasn’t until recently, after a long campaign, that the country’s biggest city started releasing data on COVID cases by residential postal code. In other words, the virus rates by neighbourhood. And you will no doubt be shocked with what that data revealed.
News Clips: We’re getting a much more detailed picture of COVID-19 cases here in the city of Toronto. Up until this point, we’ve known that it has hit low income residents and new immigrants to the city. Now we know that some areas are harder hit than others.
Jordan: So if Canada has universal healthcare, and we received the same care regardless of socioeconomic status, at least allegedly, how do we explain that map? How do we explain the voices of frontline healthcare workers who serve communities who have traditionally been underserved by the healthcare network? What do we say to them when they’re telling us that this is where we need to focus if we really want to stamp out this pandemic?
And assuming we listen to them and we do stamp out COVID-19, what measures do we need to put in place to make sure the inequitable access to healthcare doesn’t return the second the virus goes away?
I’m Jordan Heath-Rawlings and this is The Big Story. Dr. Naheed Dosani is a palliative care physician and a health justice advocate. Hello Dr. Dosani.
Dr. Dosani: Hi, thanks for having me on the show.
Jordan: No problem. Thank you for taking the time. And why don’t you just quickly start by telling us about the work you’re doing right now? Where is your clinic and what are you doing there?
Dr. Dosani: Well I work in a few roles, and certainly the experiences of COVID has changed some of the work that I’m doing, but I work as a palliative care physician in the city of Toronto and in the region of Peel, with a focused practice on providing health care to people experiencing homelessness. More recently, due to the COVID-19 pandemic, I have been working as the medical director of the region of Peel’s COVID-19 homeless response. And also [I] am the lead for a outreach palliative care program at the inner city health associates called PEACH, palliative education and care for the homeless. A mobile street and shelter based palliative care program that provides healthcare to people on the streets in shelters, under a bridge, wherever they might be so that people with serious illnesses, often terminal illnesses, can receive quality of life care.
Jordan: And what have you been seeing in your communities and the communities you work in, since COVID-19 began?
Dr. Dosani: I think COVID-19 has put a stress on the system, on people who are dependent on a system which is inequitable in a way that we’ve never seen before. It’s highlighted the fault lines, which have always existed and advocates and activists like myself have been calling out for quite some time, but it’s basically meant that people who are living in poverty, people who are experiencing housing insecurity, people who are racialized are often feeling like they are not getting equitable access to healthcare. Now we’re actually seeing that disparity gap widen for people experiencing homelessness.
There’s more people on the street than ever because respite shelters and drop ins have had to reduce hours or closed. We’re seeing a huge progression of some of the disparities we see around poverty, around food insecurity, and it’s been highly concerning to see anecdotally in the community, but also we have evidence to show that it’s having impacts as well.
Jordan: Tell me a little bit about the work you do in general, in terms of fighting inequality in the health system. I think it’s something that maybe a lot of us hadn’t considered enough until as you said, the pandemic brought it into such stark relief.
Dr. Dosani: And you know, this may be one of the silver linings of a tragedy that has been COVID-19, is that it’s brought to light issues like how social factors, the social determinants of health, impact health care outcomes. Many people are surprised to learn that over 60% of what makes us sick in our communities is actually social. The top 10 things that make us healthier, impact our ability to be healthy, the only thing that has to do with medical care is actually like number eight.
Access to a doctor, clinic or a nurse, are barely cracking the top 10. The number one determinant of health outcomes here and around the world is income, followed by other factors like housing, social networks, so on and so forth. And so this time has really pointed out that if we want our communities to be healthy, if we want people to have access to overall wellbeing, we need to pay more attention to the social factors that get us there. Interventions that help people with income, interventions that help people with housing, education and their social networks. This is how we need to move forward. And well, of course medical care is important and as a physician, I recognize that that’s important. I do know that if we really care about not just healthcare, but health, then it’s important to care about these social factors as well.
Jordan: How much work has been done since the pandemic started on identifying the communities, whether they’re people who lack housing, people who have very low income, racialized communities, as you mentioned, that are vulnerable to COVID-19. Have we, have we done that work? Do we have those numbers?
Dr. Dosani: You know, advocates have been asking for this kind of data from the very beginning. And of course, this answer varies jurisdiction to jurisdiction here in Ontario. When the pandemic started, we were hearing from health leaders that this was not necessary, that the pandemic is affecting all people equally. And I’m so grateful to my colleagues, and many people I admire who kept the pressure on, because we knew before this pandemic that people are not impacted equally when pandemics curve. For example, in the H1N1 pandemic, indigenous people were 6.5 times as likely to end up in the ICU.
Then when COVID started, we were finding out in New York city the people who were black and Hispanic were two times as likely to die as their white counterparts. What we’ve learned here in Ontario, for example, more recently, is that nearly 70% of COVID cases have happened in our most ethnically dense neighbourhoods.
Recognizing that basically COVID is impacting people who are racialized, people who are lower income, and who often work in low paid service jobs. So I’m very grateful that we have started to collect data, to collect income based data, to collect race-based data. It’s only through this collection of this information, that we’ll be able to really peel back the layers of the onion to really understand how entities like COVID-19 really are impacting people in our communities cause they’re not impacting all people equally. There are people of colour, people who are poor, people who are housing insecure, people who work in low paid service jobs, are disproportionately impacted and bearing the burden of this pandemic.
Jordan: I’m going to ask probably a fairly obvious question, but what do we know about why that is?
Dr. Dosani: You know, there’s been a lot of thoughts as to why people of colour, people who are racialized, people who are poor, might have poor health. I think a lot of it does boil down to the social determinants of health.
It’s really hard to unlink poverty, for example, and the way people live often in denser communities like apartment buildings. So that is a tough thing to unpack in addition to the social determinants of health, when thinking about the indigenous communities here in Canada, state sanctioned violence and the destruction of relationships with traditional lands, racism induced, psychosocial trauma, the economic and social deprivation and inequality which reduces access to employment, housing, education, inadequate access to social and health systems.
And overall what we call structural and medical violence, are potential contributors to poor health from a social perspective, and even causes a premature death.
Jordan: Since this began and since we started seeing where it’s really impacting people, what have you seen where you are, in the form of help for people doing the work on the front lines and communities that need it most?
Dr. Dosani: I think, just drawing from my experiences in the homelessness sector, jurisdiction to jurisdiction, coast to coast, we have seen a variable response. We’ve seen the ability for communities and regions to organize and support people experiencing homelessness to have access to hotel rooms, to prevent the spread of the pandemic.
We’ve seen mobile scaled up testing. That has occurred. We’ve seen facilities establish themselves so that people experiencing homelessness can go when they’re awaiting investigation. And for those who are COVID positive, we’ve to recovery centres pop up all over the country that are focused on medical and social care with pathways to housing.
These four pillars are really what the region of Peel’s COVID-19 homeless response is based upon. And what I’ve seen as someone who’s part of it, and talking to colleagues and working in these various programs across the country, is an incredible capacity for government to work together with advocates, with activists, with social and health organizations, with our hospitals and health regions, to actually make a dent in this thing that we thought was a problem that could never go away, chronic homelessness. And it really begs the question moving forward about what we want to do with this problem, in the sense that the COVID-19 pandemic, albeit tragic, has actually shown that we may be able to end chronic homelessness, or at least address it in a major way, because after this pandemic is over, what are we going to do? Are we going to actually ask people experiencing homelessness to go back to the streets and shelters?
I don’t think that’s appropriate. And so, I’ve seen an incredible capacity for change in a way that I didn’t know was possible, but I hope that we can continue to flex those muscles to make real social change for the future.
Jordan: Have there been any discussions of medical people you work with, or at a larger level in terms of advocates conversing with government, about what does come next? Because presumably at some point there’ll have to be some decisions made about temporary resources that are currently being used.
Dr. Dosani: Yeah, a really important question.
And I think now is the time that these conversations are starting to happen. As many of these programs are now developed. There is a huge question as to what happens to these programs after, and many jurisdictions are now realizing that if these programs are not going anywhere soon, not just because the pandemic is going to be something that will be with us for a long time, but because programming like this is important for people experiencing homelessness in every region anyway. So definitely these questions are being asked around the discussion of the collection of race-based data, and particularly addressing racism as a public health crisis and anti-black racism as a public health emergency. I’m inspired by colleagues all across the country who are calling for the collection of this data and action around this data.
So I think the discourse is getting to a place of, ‘it’s not good enough to do this for our pandemic, it’s not good enough to do this right now, we need to work together to do this for the future, and we need concrete and actionable change’. And so a lot of people are talking about what that kind of change is.
And I think we are all looking for the policy driven kind of change that last well beyond the pandemic.
Jordan: Why don’t we have that data now?
Dr. Dosani: Probably because there has been a lack of recognition of the ways that issues like pandemics, impact our communities. At the outset, if we go back into the public discourse in the media, there was a lot of conversation that was very basic actually, and it was not diving down to how particular populations were being impacted. And as someone who went out on a limb and kind of spoke about what I was seeing on social media, with media, I was personally seeing how people experiencing homelessness, people living in poverty and people of colour were experiencing this pandemic differently.
But then our health leaders were kind of resistant to collecting this data, at least here in Ontario. And it’s only when the data started to come out, that the proof was in the pudding. And so I think it kind of speaks to this kind of baseline default that many of our institutions and organizations sit in, that all people are impacted equally and all people shoulder the burden in the same way, and that’s not true.
And I think the recognition of that, at its outset, is trauma informed. It is anti racist to recognize that not all communities are impacted equally by pandemics, for example. And so I hope that this teaches us a lot of lessons for the future.
Jordan: Well tell me about the data that we do have, because Toronto, where you’re working or part of where you work, released COVID cases by postal code. Talk to me about what you thought you would see, when that came out, and what you did see, and how you felt.
Dr. Dosani: First of all, the collection of this data is the result of quite a bit of advocacy from health activists, advocates and organizations who are committed to social change in our community for people who experienced health disparities. And I’m grateful to them for their inspiration and work around this. The postal code data that has come out has confirmed what many of us were feeling anecdotally and through our experiences, that people who are experiencing COVID are people who live in dense environments.
So often apartment buildings, for example. Live in lower income neighbourhoods, often work in low-paid service jobs and are often in racialized communities. This is just the beginning of the collection of this data, and there’s so much more that needs to be looked at. We need to ask a lot more information, but it is confirming what many of us were thinking at the outset. And in one statistic, nearly 70% of COVID cases have happened in our most racialized neighbourhoods.
And so the very notion that prominent public health officials were saying that COVID is impacting all communities equally, is highly concerning. And we need to collect this data to address that. On the flip side, I’ve also heard that collecting this data may especially target these communities and that’s not true. I mean, it goes without saying that just because we see that certain neighbourhoods are more likely to have COVID-19, it doesn’t mean they’re getting it in those neighbourhoods. So we’re not trying to stigmatize communities. We believe that the collection of this data has the ability to give power to these communities and the narrative that these communities are experiencing, and so that we can tell their stories too. And so I look forward to more of this data of being collected, to glean a better understanding of the nuances of how the COVID-19 pandemic is impacting people in our communities.
Jordan: Have we done anything specifically for those communities since this data came out, are we doing any different health approaches, applying more resources there? A new strategy?
Dr. Dosani: Like many of our leading public health academics in the province and in the country, we are very much in support of universal asymptomatic testing, contact tracing. Beyond that I’m starting to hear that there is some action taking place, for example, if we know that certain neighbourhoods, low income, densely populated racialized communities are more likely to have COVID-19, why are we not testing more in those neighbourhoods?
So increasing mobile testing is very important. We really need to think about providing separate spaces for people who are infected to quarantine safely. It’s really tough when you live in an apartment with multiple family members, and you’re putting them at risk and you need to quarantine or self isolate for example, that’s very challenging. The supplying of masks with instructions on how to properly use them. We also need to plan for public health spaces appropriately, this applies to all people, of course. But when you live in close quarters or in dense areas, the summer is here. We need to plan ahead for a space to, we know what happened, at Trinity Bellwoods and the debacle that that was. But there were parks around the world where people were already planning for physical distancing with circles. And I don’t mean to pick on one park in Toronto, obviously this is a national issue. And so, let’s plan for our public spaces because people are going to be in them. Other things that we can think about is supplying air conditioners for seniors, opening cooling centres, implementing online learning packages for children, including iPads connected to wifi, distributing reloadable grocery cards to replace school nutrition programs.
I think these are some of the things that need to be called upon.
Jordan: I mean, I wanted to talk to you so that we could focus on the medical approach to inequality and the data, or lack of it, around that. But over the past two weeks, we’ve seen an explosion of anger about systemic racism.
And I would be remiss if I didn’t ask you, what role does systemic racism play in the outcomes that we’re seeing in these communities?
Dr. Dosani: You know, racism and its role systemically in impacting healthcare outcomes in Canada is something that we’ve actually known for a long time. Prior to COVID we’ve known that people who are racialized, black, indigenous, people of colour, have higher rates of heart disease, high blood pressure, diabetes, respiratory diseases and cancer. For example, black and indigenous people have lower life expectancies and often cancers are diagnosed later in life. But more importantly, black and indigenous people feel discriminated against when they receive healthcare in this country.
And race and poverty and other social factors are very difficult to unlink, and we need more research in this very area. But as a palliative care doctor, I’m very aware that there is a lot of research that shows that people who are black in our communities, are less likely to get access to adequate pain control.
And our medical education system has pieces within it and components that actually contribute to racism. There’s research to show that medical students graduate thinking that black people have thicker skin. And so they receive less pain control. In another area of medicine, we know that textbooks lack examples of people of colour, specifically black people.
So skin cancers are diagnosed later in black people. And so, from health outcomes to clinical care, to education, to even research, we are very aware that race and racism is impacting the health outcomes of people in our communities. This is not to mention, we even know about pandemics, and how it affects our indigenous communities.
And so we should’ve known better before COVID, we could have known better, but hopefully, the death of George Floyd, and the subsequent activism that has come from that has brought these issues to light in a way that has not been discussed. And so it’s not good enough to feel bad. It isn’t good enough to care because racism is a social media trend. It isn’t good enough to be non-racist. We have to be anti-racist in our health systems, with every word and every action, these concepts are more important now than ever.
Jordan: My last question is, and you kind of touched on it right there, is as you watch this anger and these protests, are you hopeful that things might change because of them? And I will add to that, are you also at the same time worried about the virus spreading at these massive protests?
Dr. Dosani: You know, I think we have to remember that people are out there because they are addressing another public health emergency around them, and that is racism. I saw a headline ‘will protests cause a second wave of COVID-19?’ And I think that I would like to have corrected those headlines to say, ‘well, racism caused a second wave of COVID-19.’ We need to do a little bit of a root cause analysis to really dig deeper as to why people are out there.
We must remember that people are out there protesting a public health crisis, police brutality, that is disproportionately affecting people who are black. And this is during a time when there is a pandemic that is disproportionately impacting people who are black and people of colour. And so there is a real desire, obviously, as a health professional, to make sure people in our communities are healthy, and I’m so inspired to see that people who protest it in cities across Canada, and around the world, in the United States, wore masks where possible, had signs so they weren’t yelling, or use drums or other noise machines. They used hand sanitizer, we heard about people who were protesting in bubbles, so they weren’t interacting with as many people.
And a lot of the protests actually maintained some distance. So they did practice with certain best principles in mind. But I think as we move forward, the reason these protests are happening is because we have not seen action, and as someone who works in health and healthcare, I’ve seen a lot from health organizations run online expressions of solidarity, but now we need to act through anti racism and not tokenism. We need to hold our organizations and institutions and health leaders as accountable for change, not what many are calling performative allyship, the theatre of being an ally.
We need real allies who are interested in real change and taking the steps towards that process because that’s not easy. So those are a couple of thoughts on the protests. And I think we need to dig deeper as to what this is all really about.
Jordan: Dr. Dosani, thank you so much, both for joining us today and for the work you’re doing in the community.
Dr. Dosani: Thank you very much Jordan, I really appreciate your time.
Jordan: Dr. Naheed Dosani, a health justice advocate and a palliative care physician. That was The Big Story, for more just like it we’re at thebig storypodcast.ca, we’re on Twitter @thebigstoryfpn. You can always reach us by email, the address is thebigstorypodca st@rci.rogers.com.
If you are feeling generous, head into your favourite podcast player, see if it lets you rate us, or recommend us or review us. Tell us what you think. Tell us what we should cover, we are always listening. Thank you for listening to us. I’m Jordan Heath-Rawling, we’ll talk tomorrow.
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